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Los Angeles Harbor College

Associate Degree Registered Nursing Program

|NURSING HISTORY & ASSESSMENT FORM |

|Circle or fill in appropriate responses. Highlight all ineffective behaviors |

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|Student: Patient’s Initials: Room # Date: Patient Profile: Age: Gender: Primary Language: English Y N If no Interpreter needed? Y N Source |

|of info: Admit date: Clinical Instructor |

|Medical/Surgical Diagnoses |

|Admitting Diagnosis: |

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|Surgical Diagnosis: |

|Medication Reconciliation |

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|1. What is your reason for seeking hospitalization (patient’s own words)? | |

| |Nursing Diagnoses to Consider |

| |(circle/highlight) |

| |-Hopelessness |

|2. Do you understand your medical diagnosis? Yes No |-Altered Health Maintenance |

|3. Describe the treatments and medications you have received: |- Altered Thought Process |

| |- Impaired Social Interaction |

| |- Ineffective Coping |

| |- Ineffective Management of |

|4. How often do you go for professional exams? (physical, dental, BP, etc) |Therapeutic Regimen |

| |- Noncompliance |

|5. Do you use any assistive devices? Yes No if yes please list: |- Other- |

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|6. How would you rate your health on a scale of 1 to 10 _/10 | |

|7. Does the patient have any physical, psychosocial or cognitive developmental lags that aggravate his/her illness or | |

|inhibit self care? | |

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|8. History of blood transfusion(s) N Y, If yes – reaction | |

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|Allergies to Dyes / Shellfish Y N | |

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|9. Allergies to medication/ food/ tape/ etc…N Y If yes – reaction(s): | |

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|10. Patient: Tobacco Y N Alcohol Y N Substance Abuse Y N | |

|11. Family: Tobacco Y N Alcohol Y N Substance Abuse Y N | |

|If #10/#11 yes, describe: | |

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|12. Any concerns you would like to discuss? | |

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Los Angeles Harbor College

Associate Degree Registered Nursing Program

|I. Physiological Modes - General Assessment: Cognitive / Sensation |

|Subjective Data |Objective Data |Nursing Diagnoses to Consider |

|Pain level /10 | |(circle/highlight) |

|Pain assessment: |General appearance: |-Impaired Verbal |

|Aching Burning Numb Piercing Pulling Sharp Shooting |Well-nourished / Thin / Obese |Communication |

|Tingling Stabbing Throbbing Dull Other Location: | |- Pain: Acute/Chronic |

| |Alert / Semi-conscious / Unresponsive |-Self Care Deficit (be specific) |

|Duration: Is pain always there? Y N Does it come and go? Y N |Other: |-Sensory/Perceptual |

|What makes it better? Worse? | |Alteration |

|Ability to communicate pain Y N If no, describe: |Level of activity: Bed rest / chair / |-Altered Tissue Perfusion: Cerebral |

| |bathroom / as tolerated |-Other |

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| |Ambulatory: assistance needed N Y (if yes, describe: | |

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| |Barriers to communication: | |

| |Aphasia N Y If yes, describe Other: | |

|Oxygenation Needs [Pulmonary/Cardiovascular/Peripheral Vascular] |

|Subjective Data |Objective Data | |

| | |Nursing Diagnoses to Consider |

|Smoking: N Y If yes, pack years If quit, how |Vital Signs |(circle/highlight) |

|long ago Cough Y N Productive Y N Dyspnea|T: PR: RR: BP: Orthostatic/postural BP: |- Ineffective airway |

|Y N DOE: Y N |Pulse Ox Oxygen via @ |clearance |

|Dizziness/Weakness Swelling |Ht. Wt. |-Impaired Gas Exchange |

|Chest pain | |-Ineffective Breathing |

|Palpitations Bleeding Bruising | |Pattern |

| | |- Knowledge Deficit |

| | |- Impaired Skin Integrity |

| | |-Alteration in Tissue |

| | |Perfusion |

| | |- Activity Intolerance |

| | |-Fatigue |

| | |-Cardiac Output: Decreased |

| | |-Other- |

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| |Regular heart rate: Y N If no, describe | |

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| |Pulses: weak / strong Peripheral pulses equal Y N Mucus membranes | |

| |pink/moist: Y N Cyanosis:Y N Capillary refill sec. Skin | |

| |temperature | |

| |Skin color Telemetry Y N Pacemaker Y N Edema degree / location | |

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| |Activity Tolerance (must do on all patients): Specify activity | |

| |Prior to activity: PR RR After activity: PR RR | |

|Pertinent Lab work and tests: RBC Hgb Hct C&S | | |

|O2 Sat BNP Chest X-ray: | | |

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|EKG: | | |

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|ABG’s: pH Paco2 | | |

|Pao2 Sao2 | | |

|HCO3 | | |

|Base Excess | | |

|Other: | | |

| |Respirations: reg / irregular / symmetrical / unlabored | |

| |/ shortness of breath (SOB) at rest/ DOE | |

| |Bilateral breath sounds noted in all lung fields Y N Diminished | |

| |Absent Crackles Wheezes Rhonchi Chest tube Y N | |

| |Cough: Y N □ productive □ nonproductive Sputum amount | |

| |Consistency: □ liquified □ thick □ blood tinged | |

| |□other Color: clear, white, yellow, brown, green, gray, other | |

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Los Angeles Harbor College

Associate Degree Registered Nursing Program

|Fluid and Electrolytes Needs |

|Subjective Data |Objective Data |Nursing Diagnoses to Consider |

| | |(circle/highlight) |

|Usual Intake: Output: Weakness/Cramping: |All intake (IV, PO, etc.) past 24 hrs All output (urine, emesis, lavage)|- Fluid Volume: |

| |past 24 hrs |Excess/Deficit |

| |Calculate fluid balance ml (positive/negative) IV Solution: |- Impaired Mental |

| |Rate: mL/hr Drop rate: gtt/min Saline lock site: Y N Patency: Y N |Faculties: Confusion |

| |Flushed: Y N Condition of Site: |- Impaired Tolerance |

| |Edema/Retention: |Deficit |

| |Hemodialysis access N Y If yes, describe |- Other- |

| |site Bruit: present: Y N Thrill: present Y N Peritoneal Dialysis N | |

| |Y If yes, describe site: | |

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|Pertinent Lab Work: Electrolytes | | |

|Na+ K+ Cl- | | |

|CO2 Ca++ PO4- | | |

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|Hct | | |

|Nutritional Needs: Gastrointestinal |

|Subjective Data |Objective data |Nursing Diagnoses to Consider |

|Usual Diet / Cultural Preferences: | |(circle/highlight) |

| |Diet: Nutritional supplements: Gavage formula: @ |- Nutrition: Altered/Less |

| |mL/hr via NG / PEG / Jejunostomy tube |than Body Requirements |

|Likes: Dislikes: | |-Nutrition: Altered/More than |

|Nausea: Y N Vomiting: Y N GERD: Y N |Difficulty chewing: Y N Difficulty Swallowing: Y N Dentures: Y N If |Body Requirements |

|Dysphagia: Y N Diarrhea: Y N Constipation: Y N|yes, partials (upper / lower) / full Abdomen Shape: soft / firm / flat / |-Swallowing: Impaired |

|Change in Appetite: Y N If yes, describe: |distended / tender / rigid / other |- Bowel Elimination: Altered: |

|Usual Weight: Recent wt loss/gain Over what|Bowel Sounds: present / sluggish / hyperactive / absent: |(Constipation) (Diarrhea) |

|time period Nutritional supplements: Y N | |-Risk for Aspiration |

|Date last BM: |Masses: N Y Hernia: N / Y Suction: continuous / intermittent / | |

| |gravity |-Other- |

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| |Ostomy: N Y type Stoma appearance: | |

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| |Self care with ostomy: Y N If no, describe: | |

| |Describe stool: | |

|Pertinent lab/tests: Serum albumin: | | |

|GI studies/X-ray: | | |

|Elimination Needs: Genitourinary |

|Subjective: |Objective: |Nursing Diagnoses to Consider |

| | |(circle/highlight) |

|Usual pattern/frequency: Any |Bladder distended: Y N Urine: yellow/amber/dark amber clear / cloudy |- Urinary Elimination: |

|difficulty/concerns: |sediment / odor Urine amount in 24 hr Void: continent / incontinent Foley|Altered: (Retention) |

| |Y N Condom Y N Suprapubic: Y N Dysuria / Polyuria / oliguria / anuria |(Incontinence) |

| | |-Other- |

| |Genital edema / discharge N Y If yes, describe: | |

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| |Ostomy: N Y type Stoma appearance: Self care with ostomy: Y N If no, | |

| |describe: | |

|Pertinent lab/tests: | | |

|BUN Creatinine Uric acid | | |

|Urinalysis | | |

|C&S (urine): | | |

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Los Angeles Harbor College

Associate Degree Registered Nursing Program

|Rest & Activity Needs/ Sleep/ Orthopedic |

|Subjective: |Objective: | |

| |Assistance needed: N Y If yes, describe |Nursing Diagnoses to Consider |

|Needs Assistance to: |Moves all extremities: Y N If no, describe: Contractures N Y If yes, where |(circle/highlight) |

|Fatigue: |Joint swelling/tenderness N Y Functional limitations N Y describe: |- Sleep Pattern |

|Weakness: |Restraints/Casts/Traction/ |Disturbance: Alteration in |

|Usual Sleep Pattern: Meds/Rituals: |Amputation: ROM Y N PT Y N Hrs. Slept Disruptions: Impaired gait /|Comfort |

|Usual Activity/ Exercise: |strength: Steady / Unsteady / Shuffles / Short steps / Not ambulatory Other |- Pain/Fatigue |

| | |- Activity Intolerance |

| | |-Risk forInjury |

| | |-Other- |

|SAFETY: Risk for Falls – Circle appropriate number |

|Previous fall |5 |Nocturia or urgency |2 |

|Impaired gait or strength |3 |Arrhythmia or postural hypotension |2 |

|Confusion or impaired judgment |5 |Decreased vision or hearing |1 |

|Sedative / hypnotic or dizzy |3 |TOTAL | |

|Risk Level: 0-2 = No Risk. 3-4 = Moderate Risk. 5 or greater = High Risk. Fall Precautions initiated Yes / No / NA |

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|RESTRAINTS: N Y MD order Restraint type Reason Circulation/Mobility Assessed: Q H. Provided Nutrition Hydration Elimination Hygiene Mobility|

|Sensory Regulation Needs: Neurological / Endocrine / Eyes / Ears |

|Subjective Data |Objective Data | |

| |Awake & oriented: person/place/time/purpose: Y N If no, describe |Nursing Diagnoses to Consider |

|Sensory changes / deficits: |Follows directions consistently: Y N If no, describe |(circle/highlight) |

| | |-Alteration in Body |

| |Eyes open spontaneously: Y N Drainage Y N Tearing Y N PERRLA / |Temperature: |

|Fatigue/Heat-Cold Intolerance: LMP: |constricted / fixed : Speech clear & appropriate: Y N If no, describe |(Hypo/Hyperthermia) |

|Postmenopausal N Y Supplementary hormones: | |-Health Maintenance |

| |Spontaneous movement: Upper Y N Lower Y N Unresponsive: Y N Lethargic: |Alteration |

| |Y N Agitated: Y N Aphasic: Y N Confused: Y N Forgetful: Y N |-Knowledge deficit |

| | |-Alteration in |

| |Hair (describe): Vision (impaired): N Y If yes, describe: |Sensory/Perceptual |

| | |-Other- |

| |Hearing: Hearing Aides: Y N | |

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| |Taste (altered): N Y If yes, describe Smell (altered): N Y If yes, | |

| |describe | |

| |Touch (altered): N Y If yes, describe | |

|Pertinent lab/tests: FSBS | | |

|Fasting glucose Thyroid Panel | | |

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Los Angeles Harbor College

Associate Degree Registered Nursing Program

|Protection Needs: Integumentary |

|Subjective |Objective |Nursing Diagnoses to Consider |

|Change in typical skin color / temperature / |Temperature: hot / warm / cool / cold |(circle/highlight) |

|condition N Y If yes, describe: |Turgor Intact: Y N If no, describe |-Skin Integrity, |

| |Jaundice: N Y Ecchymosis |Impairment, Risk for |

| |Petechiae Denuded |-Skin integrity impairment |

|Any recent change with increase of infections |Rash/Irritation |-Body image disturbance |

|(e.g. resp., urinary) N Y If yes, describe: |Lesions Incision(s) |-Coping Ineffective |

| |Drain(s) Dressing intact Y N Steri-strips Staples Sutures Drainage |-Surgical Recovery, Delayed |

| |or redness |-Injury, Risk for |

| | |-Infection, Risk for |

| |Dermal ulcers Y N Location: |-Tissue Integrity |

| |Stage Size: L W D Undermining N Y If yes, |Impairment |

| |Surrounding skin: |-Other- |

| |Drainage: N Y If yes, describe Odor: N Y If yes, describe | |

|Pertinent lab/tests: WBC | | |

|Serum Albumin | | |

|C&S: | | |

|Subjective: Risk for skin breakdown (Braden Scale) – Circle appropriate number |

|Sensory perception |Moisture |Activity |Mobility |Nutrition |Friction & Shear |

|Completely limited 1 |Constantly moist 1 |Bedfast 1 |Completely immobile 1 |Very poor 1 |Problem 1 |

|Very limited 2 |Very moist 2 |Chairfast 2 |Very limited 2 |Prob inadequate 2 |Potential problem 2 |

|Slightly limited 3 |Occasionally moist 3 |Walks occasionally 3 |Slightly limited 3 |Adequate 3 |No apparent problem 3 |

|No impairment 4 |Rarely moist 4 |Walks frequently 4 |No limitations 4 |Excellent 4 | |

|Note: Patients with total score of 18 or less are considered to be at risk for developing pressure ulcers. |Risk Assessment Total | |

|15-18 = Mild risk. 13-14 = Moderate risk. 10-12 = High risk. 9 or below = Very high risk. | | |

|II. Psychosocial Modes |

|Role function: Primary (age, gender, ethnicity): |Nursing Diagnoses to Consider |

|Secondary (husband/wife/widow/widower, etc.): Tertiary (hobbies, |(circle/highlight) |

|interests): |- Altered Role |

|What is your occupation? Retired: N Y How long |Performance |

|“Sick” role behaviors: Angry Y N Irritable Y N Withdrawn Y N Flat Affect Y N Sad Y N Anxious Y N |- Anticipatory |

|Uncooperative Y N Denial Y N Fearful Y N Demanding Y N If yes, |Grieving/Loss |

|describe |- Anxiety |

| |- Body Image |

|Stage of Illness: Health Practices: |Disturbance |

|Home environment: resides in home / multifamily home / shelter / SNF other Religion None / refuses to state / not asked |- Defensive Coping |

|Expected Developmental Stage of Life (Cho) |- Family Coping: |

| |Ineffective/Compromised |

|Growth & Developmental tasks (Cho – describe how individualized to patient): |- High Risk for Role |

|1. |Strain |

|2. |-Impaired Adjustment |

|3. |- Ineffective Individual |

|4. |Coping |

| |-Impaired Social |

|Self concept: |Interaction |

|1. Self-perception: How has your illness affected your appearance? |-Loneliness |

| |- Personal Identity |

|2. Alteration in body image: What is different about your body now? |Disturbance |

| |-Powerlessness |

| |-Role Conflict |

216

Los Angeles Harbor College

Associate Degree Registered Nursing Program

|Personal self: |-Role Failure |

|1. Self-consistency: How are your managing your life? |- Role Strain |

| |- Self-Esteem |

|2. Self-ideal: What would you like to be or do in your life? |Disturbance |

| |-Separation anxiety |

|3. Moral-ethical self: Do you have a faith that is important to you? What do you consider to be your strengths? |- Situational Low |

|What do you consider to be opportunities for improvement (weaknesses)? |Self-Esteem |

| |-Spiritual Distress |

|Dependent behaviors |-Other- |

|Help seeking: Attention seeking Affection seeking Interdependent behaviors (Assistance needed due to constraints of | |

|illness / age / etc. | |

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|Independent behaviors (initiative taking) | |

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|Obstacle mastery: | |

|III. Discharge Planning |

|1. Anticipated Date of Discharge: |

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|2. Resources Available: Persons(s): Financial: |

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|3. Do you anticipate change in your living situation after discharge? Yes No If yes, describe: |

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|4. How have you managed your health problems prior to admission? Requires home assistance: Ambulation Y N Wound & skin care Y N Meds &/or IV therapy |

|Y N Food prep Y N Shopping Y N |

|Transportation Y N Home Health Y N Hospice Y N Other If yes, describe |

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|Teaching / learning needs (current admission) Patient / Family / Other |

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|3. |

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|Diet Type % taken (1) Breakfast (1) Lunch |

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|(2) Breakfast (2) Lunch 1 = day one of care |

|TPN/Tube feeding: 2 = day two of care |

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|List specific guidelines for special diets, e.g. Low sodium, ADA, Renal: |

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|Is your patient’s diet meeting MyPlate guidelines: Y N If no, include specifics as to what to avoid and what to include to ensure adequate nutrition: |

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|Documentation completed (check when completed day 1 / day 2): |

|Vital signs (1) (2) Pain assessment (1) (2) Intake & Output (1) (2) Charting (1) (2) Focus note (describe) (1) (2) If above not completed,|

|instructor notified: Y N |

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